Health and Lifestyle Questionnaire

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Hope Harvey
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Health and Lifestyle Questinnaire Name Tday s date Date f birth Clinic visit date Please tell us the reasn fr yur visit Weight histry Desired r gal weight Height Lwest adult weight When?

1 Health and Lifestyle Questinnaire Name Tday s date Date f birth Clinic visit date Please tell us the reasn fr yur visit Weight histry Desired r gal weight Height Lwest adult weight When? Highest adult weight (nn-pregnant) When? If yu are verweight, when did yu begin gaining excess weight? Starting a new jb After High Schl After Cllege After getting married After having children After surgery/injury Please list weight lss prgrams, diets, r medicatins yu have tried, with apprximate dates: DIET START DATE END DATE Atkins LA Weight Lss Cambridge Jenny Craig Medifast Nutrisystem Optifast TOPS Suth Beach Weight Watchers : : Maximum weight lst n any prgram 1

2 Eating pattern Where are mst meals eaten? At hme alne At hme with family At hme with a friend At restaurants alne At restaurants with family At restaurants with a friend Where d yu purchase r btain fd? D yu receive SNAP Benefits? Yes N D yu have fd allergies r intlerances? Any husehld special dietary restrictins? Wh usually cks? Wh grcery shps? Favrite fds Fd dislikes Prblem fds What percent f the time d yu spend thinking abut fd and yur weight? Are yu uncmfrtable with hw much yu eat? Yes N D yu eat differently when yu are alne? D yu have difficulty chewing? Yes N D yu have truble swallwing? Yes N D yu wear dentures? Yes N D yu have difficulty swallwing pills? Yes N If yu are verweight, what are sme reasns? Lw level f physical activity Eating/snacking t many times daily Amunts f fd eaten Kinds f fds eaten Eating ut t ften Lack f knwledge Eating t fast Any eating prblems? Anrexia nervsa Binge eating Bulimia Induced vmiting Emtins assciated with eating? Anger Anxiety Bredm Cntrl Depressin Scial events Irregular meal and snack times Eating due t bredm r stress Lack f ther satisfactins Overeating when alne Using fd as reward r cmfrt Lve the taste f fd Laxative abuse Waking at night t eat Nne Enjyment Hunger Guilt Stress 2

3 D yu think yu are currently underging a stressful situatin? Yes N If yes, please explain: Activity and exercise Previus activity/exercise Current activity/exercise D yu have any f these physical limitatins? Chest discmfrt Dizziness Jint swelling Back pain Ft pain Jint pain Knee pain Leg pain Muscle pain Shrtness f breath Trn ligaments Tbacc use Never Frmer : Type Amunt Current: Type Amunt Start Date Stp Date Are yu expsed t secnd hand smke? Yes N Fd pattern Hw ften d yu have the fllwing fds and beverages? Milk, Ygurt Vegetables Fruit Red Meat Pultry Fish Sweets Regular sda Fast r fried fd Daily Weekly Seldm Never Hw wuld yu describe the size f yur servings? Small Average Large Hw much tea, cffee, r ther caffeinated beverages d yu cnsume? What ther beverages d yu drink? 3

4 Please jt dwn what yu eat and drink n a typical day, if yu have nt been keeping a fd recrd. If yu never have a typical day, please write dwn what yu ate yesterday: Breakfast Mrning snack Lunch Afternn snack Dinner Evening snack The fllwing three questins are fr bariatric patients nly thers please cntinue belw. 1. What kind f surgery are yu interested in? 2. What type f exercise d yu plan t d when recvered frm surgery? 3. Please check hw yur partner, spuse, family, friends, r emplyer feel abut yur planned surgery: Partner/spuse Family Friends Emplyer Very critical Neutral Supprtive Nt applicable Des nt knw ALL cntinue here. Please indicate whether yur medical histry includes any f these prblems: YES NO PROBLEM COMMENTS Anxiety Cancer Diabetes Depressin Difficulty breathing High bld pressure High chlesterl Heart disease Mental illness Obesity Ostearthritis Osteprsis Rheumatid arthritis Sleep apnea Stmach/digestive prblems Strke Thyrid disease 4

5 WOMEN ONLY d yu have menstrual perids? Yes N If yes, hw frequent are yur perids? Hw lng d they last? Hw heavy are they? What d yu use fr cntraceptin? If n, please check reasn: Hysterectmy Menpause D yu have any leakage f urine when yu cugh, sneeze r exercise? Yes N ALL cntinue here: Surgeries and medically related events (fr example: appendectmy, heart attack): SURGERY OR MEDICAL EVENT DATE Family histry Please indicate wh in yur family has had these prblems (include parents, grandparents, siblings and children) YES NO PROBLEM FAMILY MEMBER(S) Cancer type Diabetes High Bld Pressure High Chlesterl Heart Disease Mental illness Obesity Ostearthritis Osteprsis Rheumatid arthritis Strke Thyrid disease 5

6 Medicatins and supplements Please list any prescriptin and nn-prescriptin medicatins yu are taking. If yu have a current list, please bring it with yu instead f filling this sectin ut. MEDICATION/SUPPLEMENT DOSE MEDICATION/SUPPLEMENT DOSE Allergies Please list any drug r fd allergies r intlerances, and what symptms yu have Are yu allergic t latex? Yes N Scial histry What is yur ccupatin? Current emplyment status? Wh lives in yur husehld? Relatinship status? Hw much d yu sleep each day, n average? Usual bedtime Usual wake-up time Alchl intake: Nne Number f drinks n ccasin Number f days per week yu drink Recreatinal drugs: Yes N 6

Cayuga Center for Healthy Living Health and Lifestyle Questionnaire. Name: Date of Birth: Today s date: Clinic visit date:

Cayuga Center for Healthy Living Health and Lifestyle Questionnaire. Name: Date of Birth: Today s date: Clinic visit date: Cayuga Center fr Healthy Living Health and Lifestyle Questinnaire Name: Date f Birth: Tday s date: Clinic visit date: Histry f weight lss/gain: Desired r gal weight: Lwest adult weight: Highest adult weight